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- 1 <br /> r S <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZEL TON AVENUE-STOCKTON CA 95205-(209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADORES$ 15557 5th Street C,,,, Lathrop/95330 _ <br /> CROSS STREET Thomsen Read APN 196-240-170-000 PARCEL SIZE 9.120 Ac LAND USE APPLICATION or Government <br /> T <br /> OWNER NAME City of Lathrop _------ PHONE 209-941-7200 <br /> OWNER ADDRESS 390 Towne Centre Drive CRYISTATE/Zw Lathrop)CAI 95330 <br /> CONTRACTOR ---- <br /> CONTRACTOR ADDRESS _ frlOfh Y CrtrfStATER3r ce.,oma......,re e.caa <br /> SUBCONTRACTOR Caldomia Geotech _ PHONE 831-&WI964 _--- <br /> SUBCONTRACTOR ADDRESS 6886 vltalle Parkwey CRYISTATEar Dublin.CA 9/568 <br /> LICENSE XC57 C-61 D-09 Other NUMWt 612382 EXPIRATION DATE9IM020 <br /> DOMESTIC WELL SAMPuNG: General Mineral/Coliform Bacteria(4391) Dibromochlonopropane(4392) Arsenic(4393) <br /> 91TENDED USE DomestrcJ nvate IrtigaboNAgnoultural Industrial Water Oueidy Monitoring X Sod Sampkrg/Chwactenzabon� <br /> Pudic Water System <br /> n dnlerea im r,0— wow System Ni Conan Name a Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alleraeon/Modfication Other <br /> U Monitoring Wellts) a of wells Sod Boring(s) e a uaxgs X Geotechnical 3_a aUomps <br /> Ll Out-01-Service Well OW-Of-Service Well Renewal Cross Connection Repair <br /> El New Pump Pump Replacement _ Pump Repair _. Rause Well Casing <br /> WELL CONST1tUGTgN <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tod Push Point Other <br /> Proposed Well Depth_ fl Excavation __in diameter Open Boman Gravel Pack/Gravel Size in diameter <br /> Conductor Ca" - Rh diameter / Conductor Casing Depth _ II <br /> Well Casing Diameter _ in ThicknesslGauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seat Depth 6 Neat Cement(94 ID bag/5-10 gal waled Sand Cement - -_salt mlx/7 gal water <br /> Bentonite(20%solids) Other. --- <br /> Grout Placement 6Nthod Pumped X Free Fag Other Retardant/Accelerator(name)---- <br /> Installed By Drdler Pump Contractor Other <br /> _ <br /> Concrete PaWSW Dimensions Width 11 Length It Thick in Christy Box stow Pips <br /> Submersible Turbine Other HP Pump Set A Standing Water Level n <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MATH SAN <br /> JOAQUIN COUNTY ORDINANC , STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTH HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE MATH ALL <br /> WORKERSCOMPEN <br /> MINIMU AN NOTICE REQUIRED FOf''{R)NNSPECT/II(T]LNS-PLEASE CALL(209) 53-7697 <br /> SIGNED TlTlji/e 7I N j L� DATE <br /> 4Aq 1 �® <br /> 0/9 lot <br /> RO UHC <br /> T/y4)6" � �NP)' <br /> HT <br /> 777-1 7111 <br /> FF <br /> D /�.R ENT U 5,41E O Ij LY // <br /> Application Accepted By _1 Area / .----- Woyce IDS <br /> Grout Inspection By _ Dale SPECIAL Well Permit <br /> Pump Inspection By DAIS-�-�-�-/� WAIVER Received <br /> Soil Boning Inspection By Date 779 Constructed Well Depth R <br /> COMMENTS --- <br /> (/�. f h '111 1 if If _ - <br /> PE SC Mae elwd ChBrJlt/ Amount Dela Permit/ blvolee E MeN IDC <br /> Codes lift Service to _ <br /> END 4340 Neeed 4M401e WELL A+uw PERMIT <br />